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3: Respiratory System

Approved: 4 Nov 2010. Last amended: 8 Nov 2019.

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3.1 Bronchodilators

Gloucestershire Asthma Guideline

Gloucestershire COPD Guideline

Gloucestershire Recommended Inhaler Devices

Images of Gloucestershire Recommended Inhaler Devices

3.1.1 Adrenoceptor agonists

3.1.1.1 Short-acting beta2 agonists (SABAs)

  • Salbutamol MDI

  • Easyhaler® Salbutamol

    Salbutamol DPI

  • Salbutamol

    nebules

    • 3.1.1.2 Long-Acting Beta2 Agonists (LABAs)

  • Atimos Modulite® MDI

    Formoterol

  • EasyHaler® Formoterol DPI

    Formoterol

    • 3.1.2 Antimuscarinic bronchodilators

    3.1.2.1 Short-Acting Muscarinic Antagonists (SAMAs)

  • Ipratropium MDI

  • Ipratropium

    nebules

    • 3.1.2.2 Long-Acting Muscarinic Antagonists (LAMAs)

  • Incruse Ellipta® DPI

    Umeclidinium

  • Sprivia Respimat® MDI

    Tiotropium

    • 3.1.3 Theophylline

  • Aminophylline (Phyllocontin®) m/r

    Oral

  • Theophylline (Uniphyllin®) m/r

    Oral

  • Aminophylline

    Parenteral

    • 3.1.4 Compound bronchodilator preparations

  • Anoro Ellipta® DPI

    (umeclidinium 55mcg / vilanterol 22mcg)

  • Spiolto Respimat® MDI

    (tiotropium 2.5mcg / olodaterol 2.5mcg)

    • 3.1.5 Peak flow meters, inhaler devices and nebulisers

    3.1.5.1 Peak flow meters

  • Peak Flow Meter (standard and low range)

    • 3.1.5.2 Drug delivery devices - Spacers

    Spacers should be replaced every 12 months but some may need changing at six months.


    The spacer should be compatible with the MDI being used.


    Spacers should be cleaned monthly. Follow manufacturer's instructions.

  • Space Chamber Plus

    (one piece small volume spacer) – Compatible with most MDI devices

  • Volumatic

    (two piece larger volume spacer) – Compatible with Clenil®, Flixotide®, Salamol®, Seretide®, Serevent®, Ventolin®

    • 3.1.5.3 Sodium Chloride for Nebulisation

    Recommended

  • Sodium chloride 0.9%

    • Specific Indication

  • Sodium chloride 7%

    Cystic Fibrosis. Specialist use only

    • 3.2 Corticosteroids

    3.2.1 General

  • Prednisolone (oral)

    Note: EC preparations are not recommended

  • Hydrocortisone (IV)

    when oral unsuitable

    • 3.2.2 Inhalers

    Gloucestershire Asthma Guideline

    Gloucestershire COPD Guideline

    Gloucestershire Recommended Inhaler Devices

    Images of Gloucestershire Recommended Inhaler Devices

  • Clenil Modulite® MDI

    Beclometasone.

    Prescribe by brand name: Qvar® is 2-2.5 times more potent than Clenil®, standard (CFC-containing) MDIs and dry powder inhalers at the same dose.

  • Easyhaler® Beclometasone DPI

    Beclometasone

    • 3.2.3 Compound Preparations

    3.2.3.1 Asthma

    First choice formulary recommended inhalers for adults (≥18 years):

    Recommended

  • Combisal® MDI

    Fluticasone & salmeterol

  • Fobumix Easyhaler® DPI

    Budesonide & formoterol

  • Relvar Ellipta® DPI

    Fluticasone furoate & vilanterol

    • Specific Indication

  • Fostair® MDI

    Beclometasone & formoterol. Maintenance and Reliever Therapy (MART)

    Note: The beclometasone in Fostair® is characterised by an extrafine particle size distribution (similar to QVAR®) which results in twice the potentcy of standard formulations such as Clenil.

    • 3.2.3.2 COPD

    Specific Indication

  • Fostair® 100/6 MDI
    • Beclometasone & formoterol.
    • ICS/LABA: Restricted use, as per COPD Guideline
  • Relvar Ellipta® 92/22 DPI
    • Fluticasone furoate & vilanterol
    • ICS/LABA: Restricted use, as per COPD Guideline
  • Trelegy Ellipta® DPI
    • Fluticasone furoate, umeclidinium & vilanterol
    • ICS/LAMA/LABA: Restricted to COPD patients who have demonstrated benefits with inhaled corticosteroids, and who would otherwise require 2 separate inhalers for ICS/LAMA/LABA therapy
  • Trimbow® MDI
    • Beclometasone, formoterol & glycopyrronium
    • ICS/LAMA/LABA: Restricted to COPD patients who have demonstrated benefits with inhaled corticosteroids, and who would otherwise require 2 separate inhalers for ICS/LAMA/LABA therapy

    • 3.3 Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors

    3.3.1 Cromoglicate and related therapy

  • None

    • 3.3.2 Leukotriene receptor antagonists

    Recommended

  • Montelukast

    • 3.3.3 Phosphodiesterase type-4 inhibitors

  • Roflumilast

    COPD, as per NICE TA461

    • 3.4 Antihistamines, hyposensitisation, and allergic emergencies

    3.4.1 Antihistamines

    3.4.1.1 Non-sedating antihistamines

    Recommended

  • Loratadine

  • Cetirizine

  • Fexofenadine

    • Specific Indication

  • Rupatadine

    4th line for chronic idiopathic urticaria

    • 3.4.1.2 Sedating antihistamines

    Recommended

  • Chlorphenamine

    • Alternative

  • Hydroxyzine

  • Promethazine

    • 3.4.1.3 Allergen immunotherapy

    Specific Indication

  • Benralizumab

    as per NICE TA565

  • Mepolizumab

    as per NICE TA431

  • Omalizumab

    as per NICE TA278, NICE TA339

  • Reslizumab

    as per NICE TA479

  • Pharmalgen®

    as per NICE TA246

  • Grazax®

    Severe grass pollen allergy

  • Acarizax® (unlicensed)

    Severe house dust mite allergy

    • 3.4.2 Allergic emergencies

    3.4.2.1 Anaphylaxis

  • Adrenaline

    1 in 1,000: IM

  • Emerade®

    Adrenaline 1 in 1,000: for self-administration IM

  • Adrenaline

    1 in 10,000: slow IV injection reserved for severely ill patients where there is doubt about adequacy of the circulation and absorption from the IM site; with ECG monitoring.

  • Chlorphenamine

    slow IV injection

  • Hydrocortisone (sodium succinate)

    IV

    • 3.4.2.2 Angioedema

  • C1-esterase inhibitor

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Conestat alfa

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Icatibant

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Lanadelumab

    Prevention of recurrent attacks of hereditary angioedema, as per NICE TA606

    • 3.5 Respiratory stimulants and pulmonary surfactants

    3.5.1 Respiratory stimulants

  • Doxapram

    must be given under expert supervision and combined with active physiotherapy.

  • Mannitol (Osmohale®)

    bronchial provocation test.

    • 3.5.2 Pulmonary surfactants

  • None

    • 3.6 Oxygen

    See oxygen prescription chart and local guidelines

    3.7 Mucolytics

  • Carbocisteine

    Consider trial in COPD patients with chronic productive cough (as per NICE guidelines). Stop if no benefit within 4 weeks

  • Erdosteine

    Acute exacerbation of COPD. Respiratory Consultants only. Max 10 days.

  • Mannitol (Bronchitol®)

    dry powder for inhalation – Cystic Fibrosis as per NICE TA266

    • 3.7.1 Dornase alfa

  • Dornase alfa

    Cystic Fibrosis

    • 3.7.2 Mucous Clearing Devices

  • Acapella Choice®

    On the advice of a Respiratory Physiotherapist

    • 3.8 Aromatic inhalations

  • None

    • 3.9 Cough preparations

    3.9.1 Cough suppressants

    Recommended

  • Pholcodine

  • Methadone linctus

    cough in terminal disease

  • Morphine

    cough in terminal disease

    • 3.9.2 Demulcent and expectorant cough preparations

  • Simple linctus

    • 3.10 Systemic nasal decongestants

    Systemic nasal decongestants are classified in the BNF as being of limited therapeutic value

    3.11 Antifibrotics

  • Pirfenidone

    Idiopathic Pulmonary Fibrosis: NICE TA504

  • Nintedanib

    Idiopathic Pulmonary Fibrosis: NICE TA379

    • 3.12 Miscellaneous

  • N-acetylcysteine

    (oral) – Usual Interstitial Pneumonitis

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    Key

    Hospital / Specialist only

    Specialist initiation

    Treatment Guidelines

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